As a primary care doctor, I am contracted with several HMO insurance companies. As we all know, they like to do a thing called quality metrics monitoring and incentives. While striving for quality in medicine is a good thing, being told by non-clinical people (ie, business persons) what that means is not necessarily so.
Recently, I’ve noticed a big push for starting patients on statin medications. Basically, every diabetic should be on this medication despite their lipid levels or other qualifying conditions, at least according to some insurance companies. Why? There is recent evidence in a large-scale study that stains can reduce the risk for death due to cardiac events.
Medicine Isn’t Practiced Cookbook Style
This study is good evidence for prescribing statins in patients with diabetes and why a good portion of my patients with diabetes take these medications. However, this doesn’t apply to every patient, because medicine is not practiced cookbook style but rather with an art of putting evidence-based knowledge into clinical practice. It takes years to learn this skill, and it is not learned in a business school.
For example, I recently had an HMO representative reviewing my quality metrics with me and asking why a specific patient was not prescribed a statin medication. When I explained that the patient refused, I was simply told to prescribe it any way. However, informed consent must always take precedence, and patients are allowed to decide what medical therapies they chose to undergo, despite whether or not it represents best practices. The representative explained to me what I can say to convince the patient to take it. I explained what patient-centered care means and why patient choice matters. The representative didn’t seem to get it or even care. For them, they needed to check the box that this work was done. It was left unchecked.
In other instances, patients were not given prescriptions for statin medications because they had a bad reaction to one in the past. I was told to try a different one, even for patients with severe reactions and only very mild lipid derangements. Also, there are other classes of lipid lowering medications, and I don’t see the reason to change one that is working well and which the patient is tolerating to try one that may make them very sick. Not every patient reads the textbooks and orders their diseases to follow the appropriate clinical pathways.
A 90-year-old patient with recently diagnosed type 2 diabetes mellitus may be more likely to experience the side effects of these medications than any benefit they may derive from them. As doctors, we all know the goal of statin therapy is to prevent disease years down the road. If a very elderly patient is not having dangerously high lipid abnormalities, it is probably better to avoid these medications rather than placing them at potentially other health risks.
A Science AND an Art
Medicine has always been an art as well as a science. As doctors, we need to keep up with the evidence as it is rapidly changing. Not keeping up with the latest best practices is not acceptable. However, it is also not appropriate to practice strictly based on clinical guidelines without taking individual patient factors into consideration. That is why the practice of medicine is best left to those who are trained in these skills.
Patient health assessment should never be made based on purely financial factors. Of course, there must be a cost-benefit consideration taken into the development of new medications and therapies. However, at the individual level, the patient’s health in front of us must always be the driving factor in what therapies we offer. It is not merely a balancing act like the clown at the circus does when he is juggling many balls. Rather, it is a very fine-tuned analysis. Insurance companies fail to realize this when they take these decisions away from us and try to force their own best practices on us. It may work for populations, but it does not work for individual patients, which is who doctors work for.